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ESSAYS



CLINICAL MEDICINE



BEING

REPRINTS OF PAPERS PUBLISHED AT VARIOUS TIMES IN THE

"AMERICAN JOURNAL OF THE MEDICAL SCIENCES "



BY

BEVERLEY ROBINSON, A.M., M.D. (Paris)

CLINICAL PROFESSOR OF MEDICINE AT UNIVERSITY AND BELLEVUE HOSPITAL MEDICAL

COLLEGE ; ATTENDING PHYSICIAN TO ST. LDKE'S HOSPITAL ; CONSISTING

PHYSICIAN TO THE CITY (CHARITY) HOSPITAL, NEW YORK.



PHILADELPHIA

WILLIAM J. DORNAN
1903



THESE ESSAYS

NOW REPRINTED IN COLLATED FORM
ARE

AFFECTIONATELY INSCRIBED

TO MY
FORMER HOUSE PHYSICIANS OF ST. LUKE'S HOSPITAL

NEW YORK, FEBRUARY, 1903



CONTENTS.



Creasote as a Remedy in Phthisis Pulmonalis. (January, 1889.) . 9
On the Course and Treatment of Certain Ursemic Symptoms. (Octo-
ber, 1893.) 24

A Contribution to the Treatment of Organic Disease of the Heart.

(December, 1894.) 35

Etiology and Treatment of Certain Kinds of Cough. (November, 1895.) 58

Prognosis in Heart Disease. (December, 1899.) 68

Minor Forms of Cardiac Dilatation. (August, 1900.) ... 81

Clinical Study of Acute Myocarditis. (March, 1901.) ... 89
Chronic Myocarditis and Fatty Degeneration of the Heart. (June,

1901.) 104

Angina Pectoris. (February, 1902.) . 119

Tuberculous Pericarditis : Followed by Remarks upon Paracentesis

and Incision. (June, 1902.) . . . . . . . . 135

A Study of Some Cirrhoses of the Liver. (February, 1903.) . . 149



CREASOTE AS A REMEDY EN PHTHISIS
PULMONAL1S. 1



The use of creasote in the treatment of phthisis pulmonalis dates
back to 1830, the year in which its was discovered by Reichenbach, of
Blausko, in Moravia. Later on, it fell into disuse, like some other valu-
able medicaments, and for nearly thirty years previous to 1877 it was
practically of little or no importance in the therapeutics of pulmonary
disease. At the date just referred to, Drs. Bouchard and Gimbert again
revived interest in this drug by publishing a very complete article in
the Gazette Hebdomadaire, of Paris/' on its beneficial effects in consump-
tion. They claimed for it excellent results, and for careful, learned, and
honest observers, their account was as nearly enthusiastic as thorough
work is apt to be.

Shortly after reading of the observations or Bouchard and Gimbert,
I began to use creasote in the treatment of pulmonary phthisis, and in
a clinical lecture delivered at the Bellevue Hospital Medical College,
and published in the Medical Record of September 21, 1878, page 223, 1
mention in what manner I have used it and with what results in the
following terms :

" For several months, both in the Out-door Department of the New York
Hospital, at Charity Hospital and elsewhere, I have given dessert-spoonful
doses of the mistura creasoti of our Pharrnacopceia to lessen the quantity of
sputa in phthisis. I am very much pleased with this remedy, and believe
it merits a very extensive trial. No doubt, in lessening the abundance of
expectoration, it also diminishes the frequency of cough."

At that time, I would add, I regarded creasote as being only a good
anti- catarrhal agent, to be ranked high amongst some analogous remedial
substances whose main action consisted in the diminution of the amount
of purulent sputa, but which had little or no curative effect upon the
essential lesions of pulmonary phthisis, as we understand them.

From 1878 until 1885, the year when Jaccoud's treatise on pulmonary
phthisis, translated by Montague Lubbock, was published, I continued
to make use of creasote from time to time, but without watching care-
fully its effects, or believing that we had discovered, in the employment

1 Read before the Association of American Physicians, Washington, 1888.

2 Pages 486, 504, 522, and 620.

2



10 CREASOTE IN PHTHISIS PULMONAL1S.

of this drug, a very valuable addition to our usual medicinal means of
treating pulmonary phthisis. Jaccoud's statements about the advan-
tages resulting from the internal exhibition of creasote in this disease
impressed me very much, and from the time I first read them to the
present date I have prescribed creasote very frequently in pulmonary
phthisis, and, usually, with marked beneficial effects.

About the period when Jaccoud's work was first published the em-
ployment of antiseptic inhalations in the treatment of this disease inter-
ested me, and amongst the substances of which I made extensive use
none seemed to me of more value than creasote. A great deal of what
I could even now say with truth, in regard to the utility and evident
results of antiseptic inhalations in the treatment of pulmonary phthisis,
can be found by reference to a paper read by me on this subject, at
the second annual meeting of the American Climatological Association,
held in New York City, May 27, 1885, and, also, in a clinical lecture
entitled " Modern Methods of Treatment of Pulmonary Phthisis," 1 which
was delivered before the students of the Bellevue Hospital Medical
College, October 27, 1885, and was published in the New York Medical
Journal of November 14, 1885, page 535. In the issue of the Journal
of that date the following occurs :

" I have employed at different times a large number of inhaling fluids and
many different combinations. The fluid and combination to which I now
give the preference are creasote and alcohol, equal parts, to which I also fre-
quently add a like proportion of spirits of chloroform. This combination is
certainly very useful in allaying cough and modifying the quantity and quality
of the sputa in pulmonary phthisis. I, therefore, recommend it very warmly.
The alcohol is added to the creasote for the double purpose of diluting it and
making it more volatile; the spirits of chloroform are added, in view of the
experience of Dr. J. Solis-Cohen, of Philadelphia, to diminish local irrita-
tion and excessive cough. . . . Properly and judiciously employed, the
creasote inhalant relieves symptoms notably, and in the beginning, at least,
of pulmonary phthisis is, I believe, a means of decided utility, so far as the
possible arrest of the disease is concerned. It is important that beechioood
creasote be employed. . . . Precisely the way in which creasote is most
useful is, perhaps, difficult to state. By its antiseptic action it is possibly
destructive of bacilli ; by its local action and general effect it is certainly ot
value in combating catarrhal conditions. Where purulent cavities exist it
tends to destroy, or neutralize, putridity. These are certainly sufficiently
good reasons for its use without pursuing the inquiry further. At all events,
these inhalations do good. The physician notices it, and the patient affirms
it. In many instances they allay cough better than any cough mixture, and
they are certainly free from the great objection of destroying appetite, as
opium and morphine so frequently do."

I mention the preceding facts to show, as I trust I have been able to
do, that my interest in, and experience of, the good effects of creasote
in the treatment of pulmonary phthisis date back already several years,
and is by no means the outgrowth of later observations which have come

1 This paper was published in the Transactions of the Association. D. Appleton & Co., New
York, 1886.



CREASOTE IN PHTHISIS PULMONALIS. 11

to us mainly from Germany, and at the hands of Frantzel,' Sommer-
brodt," Guttmann, 3 Lublinski,' etc.

And here I would like to add a word of praise for that very distin-
guished therapeutician, Dr. Dujardin Beaumetz, who, in his remarkable
work on clinical therapeutics, 5 has given corroborative testimony which,
in my mind, has increased the importance of creasote as a valuable
therapeutic addition to our ordinary arsenal for the relief of phthisical
patients. In the latest edition, also, of the admirable work of It.
Douglas Powell, 6 will be found remarks of considerable value with
respect to the indications for the employment of this drug. In this
author's observation, he has been led strongly to doubt whether creasote
can be given during the hectic stage in sufficient quantities to influence
pyrexia without running a grave risk of setting up gastro-intestinal irri-
tation and destroying appetite. He regards it as being of more value
in apyrexial conditions ; he adds, however, that " when there is much
local disturbance of stomach and upper bowel, small doses of creasote
in combination with opium are sometimes of great service."

I do not wish further to weary attention with mere bibliographical
research, and refer to all the observations which have been made in
regard to the creasote treatment of pulmonary phthisis ; suffice it to say,
that it has been largely praised ; that several late observers, notably
Frantzel, Sommerbrodt, and Guttmann, are inclined to regard it as
directly curative of pulmonary phthisis, at least in its initial, or first,
stage ; that others, on the contrary, are less favorably disposed toward
it, and frankly confess that they have been disappointed in it ; and have
discovered no reliable evidence to show that creasote has any marked
beneficial action over and beyond what may be obtained from several
other anti-bacillary agents.

Naturally, the discovery of the bacillus tuberculosis by Koch, in
1882, made those observers who gave it internally, or who made use ot
it in inhalations, or, in some rare instances, by hypodermatic or intra-
pulmonary injections, 7 since that date, endeavor to establish its utility
mainly upon its antiseptic properties and upon its power " to retard the
local development of tuberculosis," which is probable, if the experiments



1 Deutsche rued. Wochenschrift, No. 14, 1887.
- Berliner klin. Wochenschrift, No. 15, 1887.

3 Zeitschrift f. klin. Med., Berlin, 1887, xiii., 488-494; and Boston Medical and Surgical
Journal, August 18, 1887, p. 161.

4 Deutsche med. Wochenschrift, Leipzig, 1887, xiii. 829.

5 Le<;ons de Clinique Therapeutique, t. 2. Paris, 1885, 4th edition, p. 549 et seq.

6 Diseases of the Lungs and Pleurte, etc. William Wood & Co. , New York, 1886, 3d edition,
p. 307.

'< See Wien. med. Presse, 1888, xxix. 87 ; Medical News, June 23, 1888, p. 696 ; The American
Journal of the Medical Sciences, February, 1888, p. 179; New Medications, by Beaumetz,
p. 192; Lyon Medical, 1885.



12 CREASOTE IN PHTHISIS PULMONALIS.

on animals of Coze and Simor, in 1883, can be relied on. 1 Hippolyte
Martin, 2 also, found that creasote failed to destroy the bacillus of tuber-
culosis, even in the proportion of 1 per 1000. This fact is said by him
to be equally true of salicylic acid (solution of 5 per cent.) ; bromine
(1 per 10,000 and 1 per 1000) ; phenic acid (1 : 1000) ; quinine and cor-
rosive sublimate (1:1000). In experiments 3 undertaken by C. T. Wil-
liams in 1883, with respect to agents which check the development
of bacilli most, it was found that quinine had manifest action in pre-
venting their development. These properties and this power are not
spoken of, and were not probably thought of, as they now are, by
Bouchard and Gimbert. They are of the opinion, however, that creasote
acts locally on the pulmonary lesion and produces marked eifects which
are also beneficial. Essentially, they believe that creasote has the effect
of promoting the growth of fibrous tissue around an area of consolidated,
or broken-down lung structure. Thus it is, with the passage of time,
that the cheesy infiltrations in the lungs become absorbed little by
little, as the softened masses (or the contents of large cavities) are
expectorated and the surrounding walls close in upon a relative vacuum
where previously necrosed tissue in a solid or liquid form was largely
present.

As will be seen by my own observations in a few cases later on, I am
inclined to share this view and believe in its exactness. 4 In regard to
it, Jaccoud writes as follows : " Creasote seems also to have some effect
upon the fundamental lesions themselves, and to promote the sclerotic
change by means of which recovery is found to occur in this disease."
(Loc. cit., p. 156.) Indeed, Jaccoud has frequently remarked, after the
bronchitis has disappeared and stethoscopic signs of a pulmonary lesion
were reduced to a minimum, that two or three months later there was
an evident and secondary diminution in the extent of the affected area,
and bronchial breathing and bronchophony on the periphery of this
area. These signs accompanying an evident improvement in the general
condition seemed to indicate evidently a sclerosis around the area of
pulmonary softening.

1 According to Schill and Fischer, who mixed tubercular sputa with many different sub-
stances and afterward inoculated them in different animals, creasote does not appear to have
any inhibitory action on the tubercular virus, (v. Mittheilungen aus dem K. Gesundbeits-
amte, 1884.

- On transformation of true or infectious tubercle into an inert foreign body under the influ-
ence of high temperatures and various reagents. Arch, de Phys., 1881, p. 93; Eevue de Med .
1882, t. ii. p. 905 ; 1883, t. iii. p. 209.— quoted by Beaumetz in New Medications, translated by
E. P. Hurd, M. D.— foot-note on p. 182.

s Proceedings of Royal Society, 1884, No. 221, quoted in work on Pulmonary Consumption,
2d ed., Philadelphia, 1887.

* This view would appear to be that, also, of Spencer, who, in speaking of the antiseptic
treatment of phthisis, concludes that in our treatment it is our aim to promote healing of the
damaged lung tissue by means of fibroid substitution. (British Medical Journal, January 28.
188S.)



C R E A S O T E IN PHTHISIS PULMONALIS. 13

As regards the anti-bacillary effects of creasote when taken internally,
or by inhalation, or both combined, I have nothing new or very posi-
tive to offer. On two occasions, in my own experience, when ordinary
care had been taken by a good examiner, bacilli which previously had
been present in considerable numbers, subsequent to treatment had
notably decreased, or completely disappeared. In other cases the exam-
inations made did not permit me to form a reliable judgment in this
regard. As to whether creasote interferes with the bacilli locally, or
through the circulation in virtue of its antiseptic properties, or whether,
in addition to its promotion of sclerosis, it merely favors general nutri-
tion whilst acting happily upon secondary, though important, symptoms,
I am not prepared absolutely to affirm. I would add, however, that I
am inclined at present to accept the latter rather than the former
belief. This conviction is based mainly upon what seems to me to be
a fair and proper interpretation of numerous facts observed by myself
and others already referred to. It is important to note, however, that I
am now decidedly of the opinion that patients, as a rule, improve more
rapidly and surely upon the conjoined treatment by means of antiseptic
inhalations and creasote given internally than they do upon either
treatment by itself. I have attained this conviction by carefully watch-
ing the effects produced when one or other of these methods was aban-
doned for a time, and afterward when both were resumed and system-
atically used. It is probable, therefore, that in many cases the frequent,
or prolonged, topical application of creasote vapors to the respiratory
tract in a considerable area is of undoubted utility and, after a manner,
not very different from what I have previously described.

Another fact of great practical importance relates to the purity of
the drug and the source from which it is obtained. For the information
of those whose attention has not been directed closely to this matter, I
would state that in New York City (and I presume elsewhere) much
of the creasote which is dispensed is simply crude carbolic acid, obtained
from the distillation* of coal-tar oil, and commonly called " commercial
creasote." It has neither the color, the odor, nor the chemical proper-
ties of wood creasote, or, what is preferable, of the creasote which is
obtained from the distillation of beechwood-tar. I am glad to believe
that the ordinary dispenser, in making this pernicious substitution, is
himself a victim of ignorance and not of knavery — at least so far as
what pertains to the therapeutic use of the drug. And yet in moderate,
or large, doses, and particularly with sensitive patients, there is a very
great difference in the effects of the two drugs. The one, viz., carbolic
acid, may prove distinctly injurious, if not poisonous ; whereas the other,
viz., wood creasote, when judiciously employed, should be followed by
favorable or perhaps negative results, but rarely, if ever, by manifest
bad consequences. I am credibly informed that the only creasote in the



14 CREASOTE IN PHTHISIS PULMONALIS.

market to-day which responds favorably to all, or most, tests of abso-
lute purity is that of T. Morson & Son, an English product, which is
mentioned on page 497 of the United States Dispensatory, and that of
Merck, a German product. Of the two products, Morson's is the one
which I prescribe and believe is purest. In order to avoid uncertainty,
or risk in prescribing, it is essential at present to designate definitely
the creasote that we wish to employ and afterward see to it that our
prescription is taken to a trustworthy pharmacist.

Through inattention to the foregoing necessary precautions, ia two
instances reported to me, somewhat poisonous effects were produced by
the internal use of carbolic acid, when it was intended that creasote
should be taken.

In my judgment, whenever creasote is prescribed it should be taken,
at least at the commencement of treatment, in small or moderate doses.
These doses should be continued a long while, or only gradually in-
creased. 1 If an attempt be made, especially at first, to take large doses
of creasote, in the majority of cases stomachal intolerance will soon
follow, and we shall be obliged either to diminish the amount prescribed
or lessen the frequency of doses, or abandon the treatment altogether
for a time. My experience is different from the personal experience of a
Russian physician, Dr. Bogdanovitch, who found no appreciable benefit
from small doses (half a grain four or five times a day), but who,
when "he began to take creasote in gradually increasing large doses,
beginning with four grains a day, and reaching in about two months a
daily dose of forty-four grains, there took place fairly rapidly an un-
mistakable and permanent improvement in his symptoms." 2 It is, also,
different from the reported observations of Sommerbrodt and Guttmann,
from the perusal of which Bogdanovitch took his inspiration.

The daily amount of creasote prescribed by me for adults, in private
practice, has varied usually from three to six minims, and continued
frequently many months without increase, or interruption, or any evi-
dence of intolerance. The ordinary dose of half a minim is repeated
every two or three hours. It is given with whiskey and glycerine,
according to the following formula, 3 which is that of Jaccoud, the sole
difference being that I use whiskey where Jaccoud employs cognac or rum :

R. — Creasoti (beechwood) tt\,vj.

Glycerine 3J.

Spts. frumenti • . |jij. — M.

S. — As directed.

1 This opinion is corroborated by that of Spencer (British Medical Journal, January 2S, 188S),
who says that the influence of the antiseptic should be continuous and prolonged.

2 British Medical Journal, March 10, 1888.

3 Whenever the mixture is taken according to this formula no addition of water is required,
and it reminds one, by its smoky odor and flavor, of slightly sweetened Scotch whiskey.



CREASOTE IN PHTHISIS PULMONALIS. 15

In hospital practice, for convenience sake, or rather so as to give the
patient a sufficient supply of medicine to last until his next visit to the
hospital, I prescribe teaspoonful doses, each teaspoonful containing one
minim of creasote, and to it are added two teaspoonfuls of water. This
addition is made to prevent irritation of the throat in swallowing the
dose. It also obviates irritation of the stomach in some instances. The
dose is ordered every three hours, so that if it is taken with absolute
regularity the patient gets eight minims of creasote in twenty-four hours.
This is rarely the case, as, owing to sleep or other causes, one or two
doses are usually omitted.

The formula which I have used in prescribing creasote is a very good
one, as in it the creasote is perfectly dissolved and sufficiently diluted, thus
preventing it from being unpalatable or irritating. The perfect solution
of creasote and its large dilution are both strongly insisted upon by
Bouchard and Gimbert in their original article as being essential points
in rendering it acceptable to patients. In Jaccoud's formula, as slightly
modified by me, we obtain the well-known beneficial effects of whiskey
and glycerine in the treatment of phthisis. I regard it, therefore, as
superior to the following, which is the one adopted by Frantzel : J

R. — Creasote n\,xv.

Tinct. gentian. ....... "ixj.

Spts. vini rect. . . . . . . . 3vj.

Vini xeres q. s.utfiant §iv.

S. — Jss ter die ex aqua.

It is well to add that only pure whiskey and glycerine should be em-
ployed, and as the latter is frequently adulterated, and hence injurious,
I would indicate Price's or Bowers's glycerine as being probably the
best.

I have also frequently prescribed creasote in gelatine capsules com-
bined with cod-liver oil. These capsules are now made by several manu-
facturers abroad, and may be readily manufactured in the United States. 2
Each capsule contains about a minim of creasote. They should be taken
fifteen or twenty minutes after meals. At other times they are apt to
cause dyspeptic symptoms. Two or three at a dose mark the limit of
stomach toleration ordinarily, and in only one or two instances have I
been able to increase this number without occasioning digestive disturb-
ance. For these reasons the capsules do not appear to me, at present,
as eligible a form to prescribe creasote as the mixture of creasote with
whiskey and glycerine.

If creasote be administered in cod-liver oil, the amount of oil must be
at least one drachm to the minim of creasote, in order to obtain a proper

1 The Year-book of Treatment for 1887.

2 Already one pharmacist in New York, to my knowledge, makes them.



16



CREASOTE IN PHTHISIS PULMONALIS.



dilution of this drug. Otherwise, if cod-liver oil be indicated for a
patient, it is desirable to give it separately, and order the creasote to be
taken in the manner first advised. This I have done in several instances,
and particularly when, despite the use of creasote, with complete stomachal
tolerance, there has been continual loss of flesh.

In a very large proportion of cases of pulmonary phthisis that I have
treated during the last year or two (and in every one of the cases herein-
after analyzed), whilst creasote was taken internally, antiseptic inhala-
tions were also used by means of the perforated zinc inhaler. As a rule,
in the beginning, the inhaler was worn during fifteen or twenty minutes
every three hours, and from ten to twenty drops of the inhaling fluid
were poured on the sponge of the inhaler at least three times in twenty-
four hours. The inhaling fluids most frequently employed by me were :

1. A combination of iodoform, creasote, eucalyptus, chloroform, alco-
hol, and ether, seemingly a somewhat formidable mixture in view of its
numerous constituents, but a very rational one when explained in detail.

2. Iodine, creasote, carbolic acid, and alcohol.

3. Creasote and alcohol.

The first one of these inhalants is a modification of one taken by me
from Lauder Brunton ; the second is that of Dr. Coghill, 1 and, according
to K. Douglas Powell, 2 " is a favorite and much used one ;" the third is
so far as I know, my own combination. The following are the precise
formulae :



R. — Iodoform i ....


.


gr. xxiv.


Creasoti ....




"liv.


01. eucalypti




Titviij.


Chloroformi




tr^xlviij. 3


Alcoholis astheris


aa q. s.


3ss.— M.


R . — Tinct. iodidi retherahs,






Acidi carbolici .


aa


3ij.






3j-


Sp. vini rect.


. ad.


Sj.-M.


R. — Creasoti ....


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